Provider Demographics
NPI:1225358740
Name:HAGEN, MARK P (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:PAUL
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4100 HORIZONS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-5280
Mailing Address - Country:US
Mailing Address - Phone:614-457-1793
Mailing Address - Fax:614-457-0704
Practice Address - Street 1:4100 HORIZONS DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-5280
Practice Address - Country:US
Practice Address - Phone:614-457-1793
Practice Address - Fax:614-457-0704
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34010866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083455Medicaid
OH0083455Medicaid